Harcourt Gardens Care Home

“Overall, people received good quality care from staff who were kind, responsive and generally understood their needs. Feedback from people, relatives and professionals was positive. We observed positive interactions between staff and people, and the environment was clean, safe and well maintained. Staff responded appropriately to changes in people’s needs, and referrals to healthcare professionals were made in a timely way.”

“However, governance systems were not consistently effective in ensuring care was delivered and recorded in line with best practice and legal requirements. We identified inconsistencies in care planning, particularly relating to Mental Capacity Act (MCA) processes, consent and end of life (EOL) planning. While these issues had been identified by the provider, they had not been fully embedded into practice at the time of inspection. This meant there was not always sufficient assurance that care was consistently lawful or person-centred.”

“We found examples where care was not consistently delivered in line with people’s preferences, including night-time routines. While these issues did not affect everyone, they demonstrated variability in people’s experiences and showed that systems were not always effective in ensuring care followed agreed plans.”

“The provider had taken steps to address these concerns, including implementing action plans and seeking external support. However, improvements were not fully embedded at the time of inspection.”

“The provider was in breach of the legal regulation relating to effective governance. Although systems and processes were in place to monitor the quality and safety of the service, these were not always effective in ensuring improvements were implemented and sustained, risks were mitigated, and records were complete and accurate.”

“We have asked the provider for an action plan in response to the concerns found at this assessment.”